96. Watching their Rome burn.

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Sorry, I’ve not written anything for a while. The daily news has become so outlandish that the art of wry observation has been killed off. It’s like a weather report has been interrupted by an extinction event meteor strike.

People keep asking me to explain why the UK is shooting itself in the foot and I suppose the easy answer is that Britain hates itself deep down. Britain is one of the first industrial countries and is the first one to become sick of industrial endeavour. The jadedness is pervasive. No-one’s really facing it. Employment is historically at a high level, but most of what people do at work they freely accept is pointless.

If Britain turned up in outpatients we’d send it to the crisis café, where it would do breathing exercises and group drumming therapy. Britain is paranoid, but not in a psychotic way. Britain is using the primitive defence mechanism of projection to blame its problems on others, much as Gotham City eventually turned against Batman. Britain will not be given drugs and universal benefit; it will not be allocated to a care coordinator. Britain will be given a self help leaflet and ‘signposted’ to the Tuesday allotment project. Sadly there is no therapist designed to treat whole countries. Although we have Prince Harry ‘starting conversations’ and the government’s behavioural insights unit.

But will that be enough to rescue us from our angry self loathing? Or do we need a proper superhero? Or even a more universally hated enemy, now that ISIS is receding and Northern Rail have settled their strike?

Beneath paranoia lies a longing for there to be someone out there who is interested in us– preferably in a good way, like a guardian angel, or Nick Knowles from DIY SOS. If they care in a negative way, such as a stalker or the taxman, that is still better than the complete indifference of a dark, empty universe. If Brexit is a cry for help, rather than a death throe, it relies on someone taking notice.

We cannot rely on International Rescue since David Milliband took over. I seriously doubt whether David has got the time to monitor every radio network in the whole world 24/7 like the Tracey brothers used to do. The closest we can come to Thunderbirds is the Air Ambulance, which is why we love it so much and keep putting coins in the collecting tin.

Maybe the giant corporations will look after us. I know that Google Rewards checks up on me regularly, knowing which shops I have been into or near. Unlike my guardian angel or Nick Knowles, Google Rewards reveals itself to me regularly with short survey messages. At the moment it wants to know whether I have spent any money in the shops and in particular what means of payment I used. Quite often it asks me how I feel about Argos. I don’t think Google would come to my rescue in an emergency, but importantly it does pay a small fee for each bit of information I send in. It might only be 6p each time, but it means at last I can say I am a paid writer.

Up there somewhere, my imagination tells me, there’s a person at a monitoring station looking at a screen, looking at what I am doing, ready to beam me up out of any trouble spot – this is what I call the rescue fantasy.

If I break down in my car I will call the AA. If I’m in a road accident the ambucopter will arrive, circle overhead for a while and land in nearby school playing fields. If my tooth breaks off the dentist will fit me in the same day and fix it during the Ken Bruce Show on Radio 2, both of us muttering answers to the popmaster quiz.

The local GP surgery reached out to me recently, inviting me for my 5 yearly check up. It’s called Health Check with the Nurse, though it is a health check with a health care assistant nowadays. In some more prosperous parts of the world it’s maybe a Health Check with a Regional Dean of Internal Medicine, or an underemployed WHO ambassador like Robert Mugabe. Next time here I suspect it will be health check with youtube and a mirror.

Anyway, the point is there is someone out there who cares about you, even if they have ulterior motives, like targeted advertising or stopping you getting diabetes.

And we’ve looked upon our parliament and political leaders to take an overview and guard us from our own foolishness. In return for their efforts we scream ‘nanny state’. But now we find our elected leaders fighting among themselves. Our ambucopter has landed, only to reveal the pilot and paramedic beating each other unconscious in a fist fight.

Some good things are happening, like the minimum alcohol pricing in Scotland, limits on fixed-odds betting terminals and quiet carriages on LNER. The police are asking us to report motorcyclists without helmets, accepting they will be anywhere within a ninety mile radius by the time details have been taken on the non-urgent line.

If The Rescue Fantasy was a movie here’s how it could all still work out:

Prince Philip has a dream of a devastated Britain that looks ever more like the set of a Mad Max movie. No More Heroes by The Stranglers plays loudly in the background.

He sends for Harry and symbolically hands over the key to the Royal Land Rover and Harry’s old army pistol. ‘You’ve got exactly 40 days to save this country from its own danged-bone-headed foolishness. You’ve been talking a lot about starting conversations, Harry. (eyes narrow) Now I’m telling you to finish the conversation.’

Training montage of Harry ploughing through piles of books: Freud, Durkheim, Nelson Mandela; exchanging ideas with world leaders; mindfulness exercises with the Beckhams; in the lab with Brian Cox; and finally, on the firing range with Prince Philip.

Cut to Parliament. Just like in Crimson Tide, at gunpoint, Harry relieves the prime minister of command, ‘You’re unfit for duty madam. And that’s the end of the conversation’.

Epilogue scene, the truth and reconciliation committee, chaired by Ant and Dec, symbolically reunited, takes evidence from the perpetrators. Harry, in the background allows himself a half smile.

Brief shot of angry Putin, smashing his vinyl copy of No More Heroes.

The End.

Post credits shot of the new Nissan X Trail, made in Sunderland after all.

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95. Acuphase wins by one vote.

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All this talk about plastic in the environment has made me think about our second favourite acetate (after vinegar). Acuphase, more properly known as Zuclopenthixol Acetate, has been widely used in acute mental health settings. For those unfamiliar with it, it is given in the form of an injection and its effect is that of an antipsychotic drug lasting between 2 to 5 days. Typically, the recipient becomes calmer and may sleep for a long period. The duration of its effect is particularly useful when treating acutely disturbed psychotic patients.

The alternatives, if the patient will not accept tablets, are repeated injections of shorter acting medications such as lorazepam or haloperidol, which need to be given at least twice a day.

Acuphase was widely used in the nineties but gradually fell out of favour.

Firstly, it is a ‘typical’ or ‘first generation’ antipsychotic. These drugs, for better and worse, were overtaken by second generation drugs such as Olanzapine and Aripiprazole. Olanzapine comes in the form of a ‘velotab’ which melts very quickly in the mouth. Aripiprazole does come in the form of an injection which theoretically lasts a few days, as well as a depot version which lasts a month. However, there are problems with both of these in terms of perceived effectiveness, or ‘street cred’. A substantial number of clinicians don’t believe that Aripiprazole is effective for rapid tranquillisation and the large majority still use lorazepam and haloperidol injections for this purpose.

Secondly, word got round that Acuphase could be a bit dangerous, causing cardiac arrhythmia or even sudden death.

And on a sub-cultural level, the use of Acuphase became associated with certain types of authoritarian ethos units, where the day staff look like nightclub bouncers and the night staff don’t like to have their poker game interrupted.

Last week I met a consultant who had wanted to use Acuphase, only to find that it was not on his hospital formulary and could only be used if approved by a Committee. On this occasion the vote in favour of Acuphase had gone through 4 to 3 in favour, continuing the Brexit – Trump trend of surprises. It’s hard to know which way the pendulum is swinging, especially with some of the older antipsychotics, which may be coming back into fashion.

You may be surprised that an NHS Consultant Psychiatrist doesn’t have the clinical freedom to prescribe a drug that has been widely used for over 30 years, but that’s another story. Some consultants don’t even drive Porsches nowadays.

This particular consultant did not work in Sussex. But if you google the word ‘acuphase’, one of the top results comes up as the Sussex NHS Trust Guidelines.

(If you google Sussex Trust what mainly comes up is headlines like:NHS trust criticised for underestimating risk of patients who killed 10 people’, but that’s another story.)

According to the Sussex Guidelines:

‘Acuphase has often been too widely and possibly inappropriately used, sometimes without full regard being given to the fact that it is a potentially hazardous and toxic preparation with very little published information to support its use.

There are many treatments in use where the evidence is not that strong.

Why pick on Acuphase then? After all, Zuclopenthixol is widely used in the form of Decanoate, where it is called Clopixol Depot Injection, and also in tablet form. Cannot one extrapolate to some extent that the acetate version will act in a similar way to the tablets or depot form? That is exactly what generations of clinicians have done, the distilled wisdom being that Acuphase works well in real life situations.

OK I accept that the distilled wisdom of clinicians can be entirely wrong, yes bleeding and cautery were in vogue for 2000 years, but in general…

The ‘finding no evidence’ game, ostensibly scientific, is highly politicised and has been used to exaggerate or diminish the fortunes of many treatments, from ECT and Lithium to psychotherapy and social treatments like day centres and walking pet dogs through care homes. Remember when our commissioners stopped the Badminton group?

The more you narrow down the focus of your question, the less likely you will find research evidence that exactly addresses the point. And if you refuse to generalise from research to your own situation, you will conclude there is ‘very little evidence to support’ treatment X or Y.

Sticking with Trusts that begin with the letter S, here’s a bit more Guideline, this time from South Staffordshire and Shropshire Trust.

These start a bit more positively than Sussex:

The (2012) Cochrane Review did not find any suggestion that zuclopenthixol acetate is more or less effective in controlling aggressive acute psychosis or in preventing adverse effects than intramuscular haloperidol and did not have a rapid onset of action. The use of zuclopenthixol acetate may result in less numerous coercive injections and low doses of the drug may be as effective as higher doses’.

But the same guidelines quickly go on to say:

Zuclopenthixol Acetate should only be considered appropriate after repeated injections of short acting antipsychotics e.g. haloperidol, olanzapine, aripiprazole.

Would you rather have one injection or several? You might get to choose though. Patient choice trumps even the drugs and therapeutics committee. If you want to have Acuphase if you get very ill, as I would, bearing in mind the alternatives, you can make an advance directive to this effect. Sussex again:

‘If used to good effect and the patient feels that they may benefit from its use in thefuture, then consideration should be given to the preparation of an advance directive’.

Sussex has the only Green Party MP in Britain. But I have checked on this and there is no evidence at all that the acetate from acuphase is affecting marine wildlife.

94. The road to Hull is paved with good intentions.

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It’s surprising how people you’d think would know better let their electronic stuff get covered in grime.

Although no-one got a Nobel Prize for inventing the microfibre cleaning cloth, one of these, plus a bit of solvent, is the answer.

Luckily Isopropyl alcohol can still be obtained legally in the UK. It’s an excellent way of cleaning computers, smartphones, spectacles etc

Or so I thought, until today, when I handed a pair of broken spectacles to the assistant manager of Specsavers. I mentioned they just fell apart while I was cleaning them. He asked me what I was cleaning them with and I replied, a little proudly, ‘isopropyl alchohol’.
‘That’s what killed them’, he fired back. ‘I’m afraid it’s smack on wrist time’. Specsavers haven’t been to the breaking bad news gently workshop.

Isopropyl alcohol should not be used on certain types of plastic, it turns out. When doctors make mistakes they are called ‘blunders’ in the press. But I’d prefer to call this one just an ‘adverse effect’. No-one is saying those spectacles weren’t clean.

There are probably other friends and relatives remembering that I cleaned their macbooks, wristwatches, phones etc and, come to think of it, they were never quite right ever again.

Isopropyl alcohol might just turn out to be everyone’s perfect scapegoat. ‘The first side of Scary Monsters never sounded quite right after you cleaned it’, people will shout at me. In the years to come the Brexit vote will probably be blamed on accidental exposure to cleaning fluid, rather than the usual ‘death wish’ theory.

To be honest, I cannot really explain my choice of solvent, except that it used to come in a tiny phial, with a cotton bud, for cleaning the heads on cassette tape machines. It seemed somehow so precious. But it was probably why cassettes never sounded very good, not even the ones called ‘metal’.

Like many interventions, from insulin coma therapy to prostate surgery, alcohol cleansing might do more harm than good. I thought that cleaning was improving the world just a little, sublimated baptism perhaps. Instead it was simply vandalism.

Such contributions are part of what I like to call the ‘behaving admirably agenda’, which I see as The Way Forward.

To be honest, I got the idea of behaving admirably from my cousin who lives in Australia. He is fantastically handy at fixing things, so that when he stays with someone, he likes to fix something as a kind of thank you note. For us, he sorted out the little wheels that guide the glass door on the shower. My cousin had taken the best aspects of the Random Acts of Kindness movement, and refined it into ‘specific and targeted acts of kindness’.

Combined with a few other thoughts I was having at the time I came to the conclusion that actions speak louder than words. Partly because Word Inflation has reached record levels. More words are being created and written down than ever before. So that the value of each written word is virtually zero. Take this blog for instance…

There are so many words about that people have taken to rendering them into cloud diagrams, so that words most frequently used get written larger and more often. Our leader, for instance, would just have the words Strong and Stable written over and over again in a very strong and stable font like Roboto Mono.

Our leader can’t even talk a good game. Which brings me to my point, which is that behaving admirably is far more difficult than initially meets the eye.

My idea of behaving admirably, while probably the same as yours, may not be the same as the lady up the road who keeps 14 cats in her bedroom, or the guy in the deerstalker hat who drives his disability scooter at 10mph round Tesco.  

That is perhaps why we have little aphorisms like, ‘the road to hell is paved with good intentions’. And phrases like ‘unintended consequences’. (A lot of aphorisms about this year – maybe the warm winter?)

While it is undoubtedly virtuous to pick up empty beer cans from the street corner and put them in the recycling, and indisputably evil to hang little bags of dog poo from tree branches, in between there are huge grey areas of ethical ambiguity. Many behaviours that are taken to be virtuous at face value, such as mindfulness exercises or prayer, could be seen as horribly self indulgent or even narcissistic, compared say with crown-green bowling or topiary.

One good intention that comes to mind is the current campaign to champion the cause of ‘mental health’. Lots of people have been piling onto the mental health bus recently, from the Royals and Prime Minister downwards, toward the self-congratulatory metropolitans who lead our Royal College.  

If we constructed a ‘word cloud’ from the mental health media coverage this year, what would it look like? The phrases ‘examination stress’ and ‘school mindfulness first aid’ would be in 96 font, whereas the words ‘schizophrenia’ and ‘psychosis’ would be written in size 8 Ubuntu Condensed. And you would need an electron microscope to reveal words like ‘Section’ or ‘ECT’.

Whilst accepting that the mental health discourse is a lot broader than that perceived through the half-moon spectacles of traditional psychiatry (smashed, as they are, by alcohol misuse) it looks as though the notion of severe illness has been drowned out of the conversation. Who would think that mental illness tends to affect older people, that it doesn’t always respond to talking a lot and sometimes disables people for years or decades?  

You could get the impression the government was piling money into mental health services, instead of shutting down all the day facilities, closing wards and sacking community support workers.

The mental health movement is well intentioned but it is all based on words. In particular the notion that the more a person speaks, the more his problems will be solved. Instead of talking, people should try behaving differently, or even admirably. Instead of shouting at your IAPT low intensity worker, why not clean the rubber bits around the washing machine door and the top of the fridge? I have just the solution for you.

Words are just clouding the picture, like the view you get through contact lenses cleaned with alcohol and cotton buds.

Sorry about that.

93. Schnauzers – they don’t need trousers.

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A family member is saving up for a Schnauzer. It turns out this is not a machine-pistol after all, but a tiny mustachioed dog. And that’s caused me to re-open the question: do dogs stack up? Not literally, but rather, are they a viable addition to the domestic panopoly, or would you be better off with a Macbook Pro, which has a similar price and processing power?

If you haven’t ticked either the box ‘visual impairment’ or ‘sheep farmer’ at first glance a dog looks like an encumbrance. It’s expensive to run, it doesn’t pay rent or tax and you can’t ride it. If it gets ill, there is only one treatment guideline, which rhymes with Millett.

The Schnauzer is supposed to be an expert in rat control, but the rat sector is well covered nowadays by enthusiastic amateur ratters like cats and owls, not to mention the contributions of big pharma, such as re-purposed warfarin.

Still, in the post-ratting era,  there’s an urban myth going round that pets are good for your mental health. Some of the advantages are probably non-specific, like gentle exercise and superficial social interaction with other owners. But I can see one big positive, which is that dog ownership, if supervised properly, is a practical revision course in behavioural psychology.

Readers of EP will already know that Behaviourism provides far more of the answer to life’s problems than people realise, diverted as they are by the false Gods Thinking and Feeling. The beauty of animal ownership is that behavioural methods are mainstream and largely unchallenged.

There is no visiting-occupational-therapy-student-from-Kidderminster to suggest trying hot yoga, no semi-retired-social-worker-who-does-homeopathy-on-the-side to suggest homeopathy on the side. Just people with big coats full of food treats.

Recently I found myself defending a dog that stands accused of being Nasty. It was alleged that the dog’s father had also been nasty. And there’s an implication, not unlike racism, that certain breeds are genetically loaded towards hooliganism.

You’ll understand that I have never owned a dog or spent much time with dogs or even studied dogs academically.

Against this, I know a man who spent decades training dogs for the RAF police, a man who travels around the world as something of a training guru. And he tells me that dogs are largely a blank canvas onto which the trainer writes a behavioural program.

So that deficiencies in animal behaviour are largely a reflection of poor quality ownership behaviour, such as giving mixed messages. The main enemy is contaminating  owner behaviour with Sentimentality. They don’t want to kiss you and they probably regard wearing a coat as a punishment, especially if it’s Tartan. Sentimentality is your problem, don’t make it the dog’s.

Which brings me to Jasmine Tree, which is near the scary butcher shop and the scary barber shop, next to the funeral directors. Jasmine Tree is a new gift shop which has opened like a poppy on a battlefield.

One person who won’t be shopping there is CG Jung, mainly because he died in 1961. Jung described sentimentality as ‘a superstructure that covers up brutality’. To be fair, he was talking about popular sentiment getting pumped up during war time. He’d have loved ‘ET’ as much as anyone else, if he’d lived to see it.

In fact he might just have seen ‘One Hundred and One Dalmatians’ if he’d ventured down to the Küsnacht Odeon in his final year.

Another psychiatrist who won’t be visiting our gift shop is Theodore Dalrymple, who wrote a book about modern life called ‘Spoilt Rotten: The Toxic Cult of Sentimentality’.

Both CGJ and TD, commenting on society, believed that Sentimentality went hand in hand with decadence and brutality.

But how does this relationship work? Is sentimentality a diversionary tactic, does it actually cause decadence, or is it an antidote to the harsher realities of existence? Do we need less sentimentality or more?

Sentimentality is by definition disproportionate. Implicit in the definition of sentimentality is that the emotional tone is overloud and wrongly focused, like the sound from a ghetto blaster. Sentimentality distorts logical thinking. It’s the force that keeps the card and flower shops flourishing, not to mention your uneconomic local hospital and those little trains with no passengers that go to Cleethorpes.

Humans attach emotions to objects but I suspect dogs only attach emotions to food items. So why do they go after an old stick or rubber ball? Because they are suckers for social approval, or have they just associated social approval with getting fed? Dogs are just one jump ahead of us in chaining together rewards.

When humans invest an object with an emotion it takes on a sentimental value. When the sentimental value brings a sense of comfort, the item is called a comfort object. We can easily delude ourselves that animals like comfort objects, but we might just as well dress them up in clothes and pretend they talk.

Originally considered as fetishes, comfort objects were officially deemed ‘OK’ by Bowlby and his colleagues, who came to regard them as a healthy and normal way of dealing with separation. After this liberation the trinket industry ran riot.

According to the object-relations school, we start to need comfort objects at the age of 4 months. It starts with an old J cloth and ends up – via a one-eyed teddy bear, and a plastic luger pistol – with a iphone 7 plus.

According to Today’s Parent,  it’s always wise to introduce toddlers to a rotating repertoire of comfort objects right from the start, like in ‘The 12 days of Christmas’. Since the legalisation and slow destigmatisation of security blankets, championed by Linus van Pelt, society has created more and more comforting items and showered them everywhere.

For every stress in life there is a comfort to cancel it out. There’s a card for every occasion, even high number birthdays, like 97.

The concept of a comfort object started out as fairly useless item such as a piece of cloth given to a baby by its mother. The power of the object can be increased by making the item attractive to touch and hold as well as by belonging to someone significant.

 

If we make a list of sentimental objects – pets, flowers, cards, fountain pens, vinyl records – we soon find that sentimental purchasing accounts for  90% of GDP.

Pretty much everything in fact, except barbed wire, rat poison and drain cleaner.

My hypothesis, which can’t be tested very easily, is that comfort objects have been created in greater numbers and greater potency as a kind of quantitative easing approach.

This has been needed because of the increasing number of discomforting objects that insult our sense of wellbeing, like news bulletins, call centres, crowded places and harsh materials like concrete and polyester.

My contention is that people have only been able to put up with the ridiculousness of modern life because of the compensatory tidal wave of comfort objects and food.

Unfortunately, we are increasingly exposed to harshness, in the media and in daily life, and there are signs that traditional comfort objects like the iphone 7, even the jet black version, may soon fail to calm us.

Tried and tested products are beginning to let us down. There aren’t enough small electronic devices left on our shopping lists that we covet so much that we’d exchange our spleen for one.

People used to lust after a Sony Walkman or an ipod. People queued all night outside the Apple shops. But that magic has died down and there is nothing new coming through. Big stores weren’t that keen on spleens anyway and rumour has it, just stacked them in recycling bins.

If there is hope, then it probably lies in the direction of Turkish Barbering and possibly now the new craze of Hygge.

In terms of physical objects, there are many suggestions on the web, like this one:

A hammerless short-barrel revolver, which you clean and oil daily, give a woman’s name to, and keep always loaded, under your pillow while you’re sleeping.

 

Or this list:

 

  • egg of Silly Putty
  • stress ball
  • unusual object or keychain attached to keyring
  • glass or stone marble
  • smooth pebble or “worry stone”
  • a couple of ordinary dice
  • a small metal or wooden figure or animal
  • tactile keypad pulled out from a broken calculator
  • your own thumbnails
  • hooded sweatshirt
  • pair of socks, gloves, or mittens
  • sunglasses
  • Koosh ball
  • miniature Slinky
  • small metal spring (round the ends off)
  • a good ink pen
  • pack of chewing gum
  • anklet, neck chain, watch, or bracelet
  • rosary or worry beads
  • piece of telephone cord
  • Monopoly game piece
  • metal bottle cap
  • shampoo bottle top
  • rubber bouncy ball or other small object from children’s vending machine
  • packet of small round candies
  • Livestrong or other similar “cause” bracelet
  • strip of cloth
  • empty cigarette lighter
  • Swiss Army-style pocketknife or pocket toolset
  • lump of sea glass
  • smooth-worn seashell
  • ankle jogging weight
  • toy figurine
  • one preferred paper clip
  • small eraser
  • guitar pick
  • mini-flashlight or LED keychain

Jasmine Tree doesn’t sell the revolver, but most of the rest is available. The Schnauzer won’t be interested in any of it though. In fact he’d prefer an amnesty on gifts, so he can get back to his ratting work.

92. Doing without experts, or even people who wear spectacles.

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The CEO presents his new organisational structure, shown here as a Venn diagram.

 

A cat is out of its bag. Not Kevin, the actual cat – he can’t get through Kevlar sacking – but metaphorically speaking.

There’s a book out called ‘Where there is no psychiatrist’. Though the phrase ‘developing world’ occurs somewhere in the description, and the front cover depicts a place where people carry water in stone jars on their heads, so probably not Mexborough, in actual fact this manual is meant for Britain itself. There is no psychiatrist in your town or mine. That fellow with the beard is just a hipster. That guy with the carefully-crafted-designer-vagrancy look you admired so much is just a vagrant. Though some people are pretending otherwise, for better or for worse, mental health is going DIY.

There are exactly ten reasons for this:

  • Very few new doctors are choosing psychiatry as a speciality
  • A lot of psychiatrists are retiring to open artisan cheese shops
  • Psychiatrists who don’t use a medical model are more expensive than social workers
  • Psychiatrists who use a medical model aren’t cool enough at parties
  • Psychiatrists have to wear a T shirt that says ‘in case of disaster I am to blame’
  • People have noticed that the NICE guidelines for mental illnesses are the same ones for every single disorder
  • Illegal drug dealers have got more and better new drugs than we have in the NHS
  • Maplin have got more and better electrical treatments than we have in the NHS
  • The GMC now require you to cut down the mightiest tree in the forest, with a herring, in order to get revalidated
  • Conspiracy theorists have stolen all our best delusions

Now that we have youtube to show us how to do every task, the main constraints on DIY are statutory regulations rather than not knowing how to do things. But where there are severe penalties for unauthorised gas fitting, there is no penalty at all for pretending to be a mindfulness therapist, or for lighting candles in people’s ears.

Surely, before we start selling prozac and zyprexa in Poundland, before we legalise ketamine, before we hang special magnets from our earlobes, there should be youtube videos on how to interpret evidence and follow logic? No mate – this is England. No-one likes an expert round here.  

91. Monster Munch – it’s silly not to.

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‘The crabs stayed with me until the day I simply decided that they bored me and that I just wouldn’t pay attention to them’ – Jean Paul Sartre.

 

I don’t like crisps that much, but at the market you can buy 10 bags of Monster Munch, marginally outdated, ‘flamin’ hot’ flavour, twenty per cent extra in each bag, for £1. Or for £2 you can buy a whole box (of 20). Or, for £2 you can get 48 bags of Marmite flavour. That’s unreal isn’t it?

Psychiatrists have dabbled with unreal experiences and created a few technical terms to describe them.

Depersonalization means a sense of unreality within the self. Derealization is a similar experience but refers to a sense of unreality outside of oneself, in the environment. Such experiences have been largely neglected, perhaps because no specific drug therapy is indicated, though an unusual coloured pill – ochre? – is surely needed.

Neither word really does justice to a situation where unlikely events seem to happen,so I propose we co-opt* a new word, Surrealization.

I propose we use this term to describe experiencing events so unlikely you tell yourself, ‘no surely, this can’t be happening’. Situations where you might have tried pinching yourself to check you weren’t dreaming, if you hadn’t seen Inception.

Surrealization is not an anxiety disorder.  Unlike ‘Deja Vu’ (due a remake?) it is not a sign of complex partial epilepsy. Nor have I been sprinkling ‘Special K’ on my Special K. I think it’s just the world getting more peculiar. I can’t prove this yet, but I’m starting to keep tabs on the modern world, using a Surrealization Diary, in the best traditions of cognitive therapy. Here are some recent entries:

I don’t like opera that much, but I find myself at a performance of Carmen in Sheffield. The cast includes a donkey and a white stallion and there has to be an awful possibility of the animals misbehaving on stage. Backstage they probably have a ton of sugar lumps for reinforcement purposes.

I begin to hear short bursts of high-pitched noise and at first I assume the radio-microphones on stage are picking up feedback from local cab operators. Then I realise there is an older gentleman sitting right next to me, starting to fiddle with his two hearing aids, which is where the noise is coming from.

The whistling noises get more frequent and louder. But after a while my neighbour takes out both hearing aids and puts them in his pocket, looks relieved and closes his eyes. But the noise continues and gets louder and more screechy. People start to look round and shuffle in their seats, but I realise he is now completely unaware of the aids ‘going turbo’ in his pockets. I try and catch his eye and signal, I point towards the hearing aids and put my finger over my lips, but he takes no notice.

Clearly we are on the edge of an awful scene, until suddenly, the man’s equally elderly female partner shakes him and shouts in his ear: ‘Take the fucking batteries out Ian, take the fucking batteries out’, which, after quite a lot of scrabbling, he manages to do. I write the acronym TTFBO in my diary.

I don’t like literary occasions that much, but this is a good one. I’m standing in a field in Lincolnshire, next to a very busy main road, at a tree planting party, listening to a small female person reading out a chapter of Winnie the Pooh. She speaks movingly but very quietly and her words are lost between the northerly gale and the massive lorries on the road behind her.

I don’t like Health Secretaries that much, but I am reading about Jeremy Hunt’s plans for dementia. Mr Hunt said seven-day services will improve for dementia patients in hospitals, with patients in high dependency care seen and reviewed by a consultant twice a day, every day of the week, by 2020. What the consultant will do when he meets each patient is not explained. We all hope and pray there will be effective treatments for dementia one day, but until then the consultant will be stuck with discussing the cricket score twice daily.

As Bernie Taupin might put it, if he ever met Jeremy: ‘but, then again, no’.

Now I’m at a blood-doning session, standing waiting in the foyer of a community centre with the other donors, waiting for the staff to finish their break. No doubt it makes sense for the staff to have a break between sessions, but it’s a bit weird to keep everyone in the hallway while the staff have their tea and biscuits. They are chatting loudly and I hear one of them explain to another how to pull a sickie by pretending to have diarrhoea. Mrs EP is with me and it is her 50th doning session and she is pumped up expecting the gold badge. But she has filled her forms in with a gel pen and she is told off. Gel pens have joined the long list of things blood donors should be careful about.

I don’t like health screening that much, but at Specsavers there is often a voucher you can get for a free eye test. Sometimes the voucher is on the back of the pay and display car park ticket. If not, under a bit of pressure, the assistant will produce an eye test voucher from under the counter, in a free spectacle case. Today there is a free voucher online, so it’s silly not to have your eyes tested, isn’t it? This is probably the best value in all of health care. It includes a careful examination of the retina by a properly trained person who can see right into your soul with a special lamp. When I ask for my prescription the assistant says I can’t have it because the copier is not working. I offer to write down a copy for myself or just take a photo with my phone. No, she says, data protection. Stupidly, I begin a short discussion about some of the urban myths surrounding information governance. Luckily they don’t have bouncers at opticians, so I leave without my prescription, but uninjured at least.

Now in my diary I am recording an attempt to get to Springfield Hospital from Tooting Bec tube,using Google Maps, missing the entrance and walking all the way round the block. My phone, though I haven’t asked it, tells me I have walked 3 miles and it congratulates me.

Back to the government then, who have been rolling out a short series of surreal announcements under the loose working title in my diary: ‘It’s not going to happen’. On 10 January the prime minister announced he’d be transforming housing estates. On 7th Feb he announced the transformation of prisons. And in March he announced that the NHS will be helping to plan a number of Healthy New Towns.

Quite likely, Surrealization is a reaction to this kind of Orwellian propaganda and luckily there is a specific therapy in the form of observational comedy and political satire.

A word of warning: if you suffer with Surrealization, it’s not safe to say so out loud. You will be stigmatized as awkward, cynical, negative, old or grumpy. And you will quickly be told to TTFBO.

*Co-opt because the term has a limited meaning in the arts, such as creating drama out of dream material. That’s not a problem as a lot of technical words in psychology have a day job, such as Obsession, and many of them moonlight as fragrances too.

90. Spoiling the ship for a ha’p’orth of warhead.

cipramil

Keeping the doctor away: one apple and three bottles of Cipramil.

 

2016 is turning out to be the year of the internal saboteur, but the abbreviation I.S. is already taken. Examples are all around us of people deliberately choosing to inhibit their functioning.

In this town, people are dying their own hair green and getting misspelled tattoos like ‘No Regerts’. New buildings are getting fewer parking spaces than needed, not enough to discourage people from using cars, but just enough to inconvenience everyone. The Royal Bank of Scotland has told us to sell everything and put the cash in the freezer disguised as a chicken korma.

On a national level our politicians are fighting amongst themselves in each party. Jeremy Corbyn is suggesting running the Trident subs without the nukes on board. There’s a doctors’ strike that no-one can fully understand. And, in an unbelievable U turn, the chief medical officer says alcohol is really bad for you after all.

And if this wasn’t bad enough, David Bowie has died.

Psychoanalysts were good at explaining this kind of thing, examining the metaphorical bullets that people fired into their metaphorical feet, but they are gone, replaced by computerised CBT and web-based expressive writing.

There’s a theme to this: Medical Nemesis, which was the name of a book by Ivan Illich. Ivan’s idea was that doctors had medicalised significant areas of normal life and were set to colonise all human experience, by deeming everything to be Medical. Illich felt there was an inevitability to this process, much as he felt Communism would conquer the world, domino by domino. He also pointed out that a large amount of medical activity was counter-productive, so that the net effect of modern health care was marginal and in due course would become detrimental on balance.

Medical Nemesis was published in 1975, which was the year I went to medical school and David Bowie released Young Americans. Eerily and probably coincidentally, the rise and fall of Psychiatry as a successful enterprise has run in parallel with Bowie’s career. Studying the two timelines, the Bowie discography versus the history of psychiatry, there is a broadly positive correlation, with a slow decline after 1983. I expected to see something significant in 1990, to coincide with the launch of Clozapine, but there is only Tin Machine. No model is perfect.

The theme to our current medical nemesis is this: the counterproductive effects of medicine have been escalated so that they now outweigh the positive effects. After a brief period of medical effectiveness – basically the  few weeks that followed shutting down the cholera pump on Broad Street – we are back to doing harm to people.

It’s a bit complicated to say why, but we’re talking about the net effect. There is no doubt that some medical activities are helpful, such as removing marzipan and toy animals that children have accidentally stuck in their ears. But a lot of the old certainties, like spraying the countryside with antibiotics, are over.

Even in 1975, we were taught that the increasing life expectancy that occurred in the twentieth century was mainly due to improvements in hygiene and public health, rather than laser surgery and machines that went beep. Now it is possible that life expectancy is set to reduce. It is already reducing for those who are now in later life, particularly women.

Some of the factors that have inhibited the usefulness of medicine came from outside the profession, such as the food and alcohol industries. Some have come from health industry predators, such as management consultants. Mostly however, the bullets fired into the soft underbelly of medicine have been fired by doctors themselves. For those who like acronyms, the health industry has fallen victim to the 3 P’s, namely: Pomposity, Pretension and Ponderousness. These are the outward signs that medicine has gone where it doesn’t belong, ‘medicine gorn mad’ as Dr Allenby would have said.

Focussing on Mental Health for a moment, we are living through a very unhappy period. Round about the time that Illich wrote Medical Nemesis and Bowie became the thin white Duke, the treatment of mental illness was hitting a purple patch. Psychiatrists still worked out of large mental hospitals with hundreds of beds. About a third of the beds were occupied by patients with poor-outcome psychosis, the ones we pretend now don’t exist. Another third were allocated to elderly patients with dementia. Hospitals had wards that could deal with acutely disturbed psychotic patients, without bundling them into a van and sending them to a private hospital two hundred miles away.  But most of the patients were already in the community and there were satellite clinics and community nurses in most towns. Drug therapy, with the exception of Clozapine, had already peaked, using typical antipsychotics and tricyclic antidepressants. Medical training still revolved around the ‘firm’ model, each firm belonging to a Consultant. Trainees learned all the German words for mental phenomena and sat a proper exam with essays and a long case. There was no purchaser provider split. Hospitals were administered, not managed, by a triumvirate of administrator, nurse and doctor.

Can it be possible, 40 years later, with all the endeavour that has gone into research, reorganisation and regulation, all the millions of hours people have spent in committee meetings and working parties, all the billions of pounds spent on management consultants, that our services have actually deteriorated?

Making such an assertion, one is quickly accused of being a grumpy old man or woman. Suffice it to say that not everything a senior or experienced person says should be discounted automatically (just most of it).

There are many examples however of monumental enterprises that fail. The best known are IT projects like ‘Connecting for Health’ which was wound up in 2013, having spent more than £14 billion. The audit office concluded that ‘it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme’. A scenario right out of Illich’s book.

Not only does medicine go where it doesn’t belong. Often it abandons areas where it does belong. For example, ECT. Without wishing to denigrate ECT, the evidence base for its usefulness is quite limited. Suffice it to say it probably works for certain types of acute psychotic condition, mainly the ones that it’s not used for. A lack of evidence that ECT was effective at all did not stop the Royal College setting up a complex system of training and accreditation, called ECTAS. It’s guidelines, along with those written by NICE, were stringent enough to put most ECT units out of business, much to the delight of those opposed to ECT, which is practically everyone.

Now, newer types of electrical and magnetic stimulation are coming out of the closet which are not evidence based or regulated or subject to the protective effects of the mental health act. For better or worse, ECT was regulated to death, but my tip is to hang on to those electrodes for now, pending the development of ‘swimming with electric eels’ holidays.

If Illich’s theory was correct, we would arrive at a point where medicine – in terms of its beneficial effect on society –  is taking exactly 100 steps backwards for every 100 it takes forwards. What is unclear is whether we have entered the recession yet. How will we know when the oil tanker of medicine has reached a standstill relative to the sea bed?

A possible indication of such a low point would be, say, identifying a medical condition that has recently been invented, by annexing an aspect of normal life. A condition that has escalated dramatically, filling thousands of outpatient clinics. A condition that can’t be treated effectively by health services. A condition where treatments are poorly evidenced and have clear harmful effects, like stunting growth. You know where I’m heading: by 2003, nearly 8% of American children were diagnosed ADHD. By 2011 this figure is said to have reached 11%, with a large increase in girls diagnosed with the disorder. As with life expectancy, and as Bowie would have noted, girls are the new boys.

In the metaphorical history of psychiatry then, ADHD falls into the long dark period, somewhere between Reality and The Next Day.